An 83-year-old woman with oropharyngeal dysphagia was prescribed
enteral tube feeding with Isocal 1200 mL and water 200 mL by a
dietician. After 8 weeks, she presented with hypotension, dehydration,
and altered conscious state. Blood tests showed severe hyponatraemia
(serum sodium, 95 mmol/L) and hyperkalaemia (serum potassium, 6.3
mmol/L). Her daily intake of sodium and potassium was reviewed and
found to be low (26.4 and 38.4 mmol, respectively). The formula was
replaced with Isocal HN and sodium chloride tablets were added. The
total daily intake of sodium and potassium was increased to 78 and
49.2 mmol, respectively. Both hyponatraemia and hyperkalaemia were
corrected and her serum electrolyte remained normal at the 1-year
follow-up.

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